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| SAMPLE OFFICE VISITS |
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Code |
Procedure |
Enrollee Pays |
| Sample visit #1 |
D0999 |
Office visit |
$ 5.00 |
| |
D0150 |
Comprehensive Oral Exam |
No Cost |
| |
D0210 |
X-rays |
No Cost |
| TOTAL |
|
|
$ 5.00 |
| Sample visit #2 |
D0999 |
Office visit (6 month checkup) |
$ 5.00 |
| |
D0160 |
Detailed oral exam |
No Cost |
| |
D0210 |
X-rays (if needed) |
No Cost |
| |
D1120 |
Prophylaxis (child) |
$ 15.00 |
| TOTAL |
|
|
$ 20.00 |
| Sample visit #3 |
D0999 |
Office visit |
$ 5.00 |
| |
D0160 |
Detailed oral exam |
No Cost |
| |
D0210 |
X-rays |
No Cost |
| |
D7111 |
Single tooth extraction |
$ 25.00 |
| |
D9215 |
Local anesthetic |
No Cost |
| TOTAL |
|
|
$ 30.00 |
| Sample visit #4 |
D0999 |
Office visit |
$ 5.00 |
| |
D2140 |
One surface amalgam filling |
$ 26.00 |
| |
D2330 |
One surface resin filling |
$ 35.00 |
| |
D9215 |
Local anesthetic |
No Cost |
| TOTAL |
|
|
$ 66.00 |
| Sample visit #5 |
D0999 |
Office visit |
$ 5.00 |
| |
D0160 |
Detailed oral exam |
No Cost |
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D2791 |
Crown - full cast predominantly base metal* |
$ 295.00 |
| TOTAL |
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|
$ 300.00 |
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| *May require build-up at additional cost |
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